We propose to create a Center for Patient Safety in Neonatal Intensive Care to reduce medical errors and e and enhance patient safety for high- risk newborns Our focus will be on "determining to learn most effectively from medical errors and then communicate that information to patients and families". The Center will bring together a multi-disciplinary team of experts from the University of Vermont, Harvard Medical School, and Dartmouth Medical School to create a broad foundation of knowledge regarding the causes and prevention of errors in NICUs. A key feature of our proposal is our partnership with the Vermont Oxford Network, Inc ((Network), a non-profit organization with over 350 NICUs or approximately two-third of all NICUs in the US as members. These units contribute to a common database of very low birth weight infants, conduct randomized clinical trials, and collaborate on quality improvement. The collaboration between the Center we are proposing and the Vermont Oxford Network as delivery system will provide a unique opportunity to influence medical practice at a broad range of units from around the country. The Network will participate in dissemination of educational materials through its national meetings, formal improvement collaboratives and the Internet site, NICU.org. The Network will also work closely with the Center to recruit performance sites for the pilot study. In the first year of the development grant, the Center in collaboration with the Vermont Oxford Network will complete a comprehensive review of the research literature; examine existing error prevention models in health care and other industries; obtain input from consumers, families, public and private agencies; and create a plan for a pilot study that addresses NICU errors. The Center will also create and disseminate a wide variety of educational programs and materials on safety in the NICU during its first year of operation. The second two years of the grant will be devoted to completing a pilot study focused on NICU safety. Pilot studies will focus on identifying causes of medical errors in the NICU and finding solutions to prevent such errors. Three sample pilot projects are included in this proposal. They address the areas of voluntary reporting of errors and near misses by health professionals, identification of errors and near misses through structured chart review and creation of specific neonatal "triggers", and the role of families in the identification of medical errors of high-risk newborn infants.